Gregory D. Cramer

The purpose of this case report is to describe self-administered lumbar traction as a component of the treatment of a patient with low back pain (LBP). A 41-year-old male chiropractic student presented with an exacerbation of intermittent LBP of approximately 2 years duration. Pain intensity was 4 to 8/10 on a verbal pain scale the day after exertion and 10 on the Patient Reported Outcomes Measurement Information System (PROMIS) 3a. Pain interference was 15 on the PROMIS-8a. The Oswestry Disability Index was 30%. Radiographs showed mild bilateral arthritic changes throughout the lumbar spine and sacroiliac joints. Diagnoses of acute exacerbation of recurrent, mechanical low back pain with thoracic and lumbar segmental dysfunction, lumbosacral spondylosis without myelopathy, and bilateral sacroiliac joint arthritis were made. The student received 14 treatments over 5 weeks consisting of spinal manipulation and therapeutic exercises in conjunction with clinician-supervised, self-administered traction. After 14 treatments, the patient was discharged, reporting resolution of LBP (pain intensity [PROMIS-3a] = 4; pain interference [PROMIS-8a] = 8; Oswestry 2%; and increased range of motion). Pain resolution remained for more than 2 years without additional treatment (pain intensity = 3; pain interference = 8; Oswestry 0%; continued increased range of motion). The patient reported long-term benefit from a course of spinal manipulation and therapeutic exercises in conjunction with novel self-administered traction with flexion.

Objective: This project compared student learning and satisfaction of an anatomy review delivered by a face-to-face lecture (F2FL) and an online learning module (OLM) for third-year doctor of chiropractic students. Methods: This cohort study compared student learning and satisfaction of a pediatric spinal anatomy review delivered via F2FL (cohort 1, n = 23) and OLM (cohort 2, n = 18) in 2 successive 2019 (pre-COVID) course offerings. Previously validated pre- and post-tests were given. Students completed a survey assessing delivery, comfort with online learning and online learning technology, and preference of F2FL vs OLM of review material. Pre- and post-test results were assessed using repeated-measures analysis of variance. Results: Testing results showed an improvement with both groups (F2FL 53.7%, p < .001 vs OLM 51.8%, p < .001), with no significant difference between the F2FL and OLM groups (p = .53; p = .82). The survey showed: 83.3% of OLM students felt the online method was effective, and 88.9% of the OLM students would prefer online reviews or have no preference between online or face-to-face; meanwhile, 80% of the F2FL group thought the lecture engaging/effective, whereas 60% of the F2FL group would have preferred to have the material presented online. Conclusion: The OLM was found to be as effective as the F2FL for the content assessed. The majority of students would prefer the online method for future anatomy review content presented in the course. This strategy could be applied to provide review materials in other clinical courses, allowing material to be developed and given by content experts while freeing valuable in-class time.

Crepitus vibrational and acoustic signal analysis of the human facet joints of the lumbar spine has historically been a difficult problem due to the inhomogeneous and varied signal characteristics. Although previous studies have examined tribological characteristics of facet joints, we have found vibrational and acoustic signals to be a satisfactory analog to facet joint tribology and function. Here, we improve upon our previous automated computational method, now enhancing it for the analysis of human crepitus. Compared with this group’s previous studies using a mechanical model, human crepitus is extremely complex. Therefore, we proposed an automated method (AM) of analysis that used a test set (n = 16) and an experimental set of data (n = 48). We had a fair level of interrater agreement (Kw = 0.367, standard error (SE) = 0.054, 95% confidence interval (CI) = 0.260–0.474) between the AM and human observers before adjustments were made in the AM. Following adjustments to the AM, interrater agreement improved to a substantial level (Kw = 0.788, SE = 0.056, 95% CI = 0.0.682–0.895). In the future, we recommend a machine learning study with a larger number of subjects who can better capture the nuances of varying types of human crepitus.

The vibration and acoustic emissions produced within facet joints of the lumbar spine, known as crepitus, can be a potential biomarker to identify decreased joint functioning and the site of low back pain. Using piezoelectric accelerometers and a silicone “phantom” mechanical model, we sought to identify the site of crepitus. Past analyses of these data with human observers have been too time consuming for eventual practical clinical application, and a more expedient algorithmic method of analysis is preferable. In this study, the signal filtering and processing functions of matlab were harnessed to filter aberrant noise as well as determine the location (level and left or right side) from which crepitus originated during induced crepitus events in the phantom model (n = 30). Development of this automated method refined the definition of facet joint crepitus. The automated method was found to be as reliable and valid as assessment by human observers and took significantly less time (p = 0.009). Future studies will assess the reliability of the automated method to detect this phenomenon in humans.

The purpose of this study was to assess a novel method of lumbar spinous process (SP) palpation by using magnetic resonance imaging (MRI) high-signal marker reference standards for verification. Clinicians (doctors of chiropractic) in this study used either: (1) the standard/traditional method of identifying the L4 SP using the supracristal plane (n = 14) or (2) a novel method that manually induced sacral motion to identify the L5 and then the L4 SP (n = 54). The clinicians, blinded to the results of each other, used a grease pencil to mark the location identified as the L4 SP. An MRI high-signal marker then was taped across this location. The MRI scans were assessed by a radiologist, blinded to the palpation method, who extended a line posteriorly from the superior and inferior extent of the L4 SP and determined whether the high-signal marker was within the lines bordering the L4 SP (ie, "on-target"). Palpation using the traditional method showed a 35.7% accuracy, with 5 of 14 "on target" and all "off target" being too superior. Palpation using the novel method showed 77.8% accuracy, with 42 of 54 "on target" and 3 "off target" being too superior and 9 "off target" too inferior. The novel method performed better than the traditional method. The novel method shows promise. Additional prospective research should be conducted to fully assess the accuracy of the novel method compared with traditional methods of palpation.

This feasibility study used novel accelerometry (vibration) and microphone (sound) methods to assess crepitus originating from the lumbar spine before and after side-posture spinal manipulative therapy (SMT). This study included 5 healthy and 5 low back pain (LBP) participants. Nine accelerometers and 1 specialized directional microphone were applied to the lumbar region, allowing assessment of crepitus. Each participant underwent full lumbar ranges of motion (ROM), bilateral lumbar SMT, and repeated full ROM. After full ROMs the participants received side-posture lumbar SMT on both sides by a licensed doctor of chiropractic. Accelerometer and microphone recordings were made during all pre- and post-SMT ROMs. Primary outcome was a descriptive report of crepitus prevalence (average number of crepitus events/participant). Participants were also divided into 3 age groups for comparisons (18-25, 26-45, and 46-65 years). Overall, crepitus prevalence decreased pre-post SMT (average pre = 1.4 crepitus/participant vs post = 0.9). Prevalence progressively increased from the youngest to oldest age groups (pre-SMT = 0.0, 1.67, and 2.0, respectively; and post-SMT = 0.5, 0.83, and 1.5). Prevalence was higher in LBP participants compared with healthy (pre-SMT-LBP = 2.0, vs pre-SMT-healthy = 0.8; post-SMT-LBP = 1.0 vs post-SMT-healthy = 0.8), even though healthy participants were older than LBP participants (40.8 years vs 27.8 years); accounting for age: pre-SMT-LBP = 2.0 vs pre-SMT-healthy = 0.0; post-SMT-LBP = 1.0 vs post-SMT-healthy = 0.3. Our findings indicated that a larger study is feasible. Other findings included that crepitus prevalence increased with age, was higher in participants with LBP than in healthy participants, and overall decreased after SMT. This study indicated that crepitus assessment using accelerometers has the potential of being an outcome measure or biomarker for assessing spinal joint (facet/zygapophyseal joint) function during movement and the effects of LBP treatments (eg, SMT) on zygapophyseal joint function.

Online education programs are becoming a popular means to disseminate knowledge about evidence-based practice (EBP) among healthcare practitioners. This mode of delivery also offers a viable and potentially sustainable solution for teaching consistent EBP content to learners over time and across multiple geographical locations. We conducted a study with 3 main aims: 1) develop an online distance-learning program about the principles of evidence-based practice (EBP) for chiropractic providers; 2) test the effectiveness of the online program on the attitudes, skills, and use of EBP in a sample of chiropractors; and 3) determine the feasibility of expanding the program for broader-scale implementation. This study was conducted from January 2013 to September 2014. This was an exploratory randomized trial in which 293 chiropractors were allocated to either an online EBP education intervention or a waitlist control. The online EBP program consisted of 3 courses and 4 booster lessons, and was developed using educational resources created in previous EBP educational programs at 4 chiropractic institutions. Participants were surveyed using a validated EBP instrument (EBASE) with 3 rescaled (0 to 100) subscores: Attitudes, Skills, and Use of EBP. Multiple regression was used to compare groups, adjusting for personal and practice characteristics. Satisfaction and compliance with the program was evaluated to assess feasibility. The Training Group showed modest improvement compared to the Waitlist Group in attitudes (Δ =6.2, p < .001) and skills (Δ =10.0, p < .001) subscores, but not the use subscore (Δ = −2.3, p = .470). The majority of participants agreed that the educational program was ‘relevant to their profession’ (84 %) and ‘was worthwhile’ (82 %). Overall, engagement in the online program was less than optimal, with 48 % of the Training Group, and 42 % of the Waitlist Group completing all 3 of the program courses. Online EBP training leads to modest improvements in chiropractors’ EBP attitudes and skill, but not their use of EBP. This online program can be delivered to a wide national audience, but requires modification to enable greater individualization and peer-to-peer interaction. Our results indicate that it is feasible to deliver an online EBP education on a broad scale, but that this mode of education alone is not sufficient for making large changes in chiropractors’ use of EBP.

This study tested the reliability of a 5-point ordinal scale used to grade the severity of degenerative changes of zygapophyseal (Z) joints on standard radiographs. Modifications were made to a Kellgren grading system to improve agreement for grading the severity of osteoarthritic changes in lumbar Z joints. These included adding 1 grade of no degeneration, multiple radiographic views, and structured examiner training. Thirty packets of radiographic files were obtained, which included representation of all 5 grades including no degeneration (0) and Kellgren's 4-point (1-4) joint degeneration classification criteria. Radiographs were digitized to create a radiographic atlas that was given to examiners for individual study and blinded evaluation sessions. Intrarater and interrater agreement was determined by weighted κ (κw) from the examination of 79 Z joints (25 packets). Using the modified scale and after training, examiners demonstrated a moderate-to-substantial level of interrater agreement (κw = 0.57, 0.60, and 0.68). Intrarater agreement was moderate (κw = 0.42 and 0.54). The modified Kellgren 5-point grading system provides acceptable intrarater and interrater reliability when examiners are adequately trained. This grading system may be a useful method for future investigations assessing radiographic osteoarthritis of the Z joints.

Evidence based practice (EBP) is being increasingly utilized by health care professionals as a means of improving the quality of health care. The introduction of EBP principles into the chiropractic profession is a relatively recent phenomenon. There is currently a lack of information about the EBP literacy level of US chiropractors and the barriers/facilitators to the use of EBP in the chiropractic profession. A nationwide EBP survey of US chiropractors was administered online (Nov 2012-Mar 2013) utilizing a validated self-report instrument (EBASE) in which three sub-scores are reported: attitudes, skills and use. Means, medians, and frequency distributions for each of the sub-scores were generated. Descriptive statistics were used to analyze the demographic characteristics of the sample. Means and proportions were calculated for all of the responses to each of the questions in the survey. A total of 1,314 US chiropractors completed the EBASE survey; the sample appeared to be representative of the US chiropractic profession. Respondents were predominantly white (94.3%), male (75%), 47 (+/− 11.6) years of age, and in practice for more than 10 years (60%). EBASE sub-score means (possible ranges) were: attitudes, 31.4 (8–40); skills, 44.3 (13–65); and use, 10.3 (0–24). Survey participants generally held favorable attitudes toward EBP, but reported less use of EBP. A minority of participants indicated that EBP coursework (17%) and critical thinking (29%) were a major part of their chiropractic education. The most commonly reported barrier to the use of EBP was “lack of time”. Almost 90% of the sample indicated that they were interested in improving their EBP skills. American chiropractors appear similar to chiropractors in other countries, and other health professionals regarding their favorable attitudes towards EBP, while expressing barriers related to EBP skills such as research relevance and lack of time. This suggests that the design of future EBP educational interventions should capitalize on the growing body of EBP implementation research developing in other health disciplines. This will likely include broadening the approach beyond a sole focus on EBP education, and taking a multilevel approach that also targets professional, organizational and health policy domains.